<html><body bgcolor="#FFFFFF"><div>Great post Art.</div><div><br></div><div>But right now with the dignostic things at our disposal are there some symptoms/presentations that should not be dignosed by those without the training? </div><div><br></div><div>A little like using a stethoscope with a hearing deficit? </div><div><br></div><div>And how do you know you have not had the training, or have significant hearing loss at different frequencies?</div><div><br></div><div>And is the variation seen added to with different patients from around the world?</div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "><br></span></div><div>As you say<span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "> a lot of pressure on the primary care physician. No<span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "> wonder with too great a volume of patients there is burn out. </span></span><br></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "><br></span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); ">Are there technological supports to improve things?</span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "><br></span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); ">Could we triage out the more serious things? And we do that to some extent, but we still miss PE.</span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "><br></span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); ">Could we use simulation training? would that help? But it seem that we should ybe doing something different.</span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); "><br></span></div><div><span class="Apple-style-span" style="-webkit-tap-highlight-color: rgba(26, 26, 26, 0.296875); -webkit-composition-fill-color: rgba(175, 192, 227, 0.230469); -webkit-composition-frame-color: rgba(77, 128, 180, 0.230469); ">Rob Bell</span></div><div><br></div><div><br></div><div><br>Sent from my iPad</div><div><br>On Feb 25, 2016, at 9:02 AM, Art Papier <<a href="mailto:apapier@VISUALDX.COM">apapier@VISUALDX.COM</a>> wrote:<br><br></div><div></div><blockquote type="cite"><div><div class="WordSection1"><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D">Variation in presentation is a great thread and topic for this listserv.   In dermatology, variation is much more obvious than in perhaps other specialties.  We take our first year residents and train their eye to recognize variants.  By the time they finish their residencies the best ones can see scabies presenting 10 different <i>typical</i> ways.  Experience and feedback loops cements for these residents the variation.   The variants actually are common and become typical for the expert.   But this is by no means easy or expecting from physicians, NP’s or PA’s that have to deal with any patient complain across medicine.  The diagnostic error that we often see coming from primary care or the ED almost always is an unrecognized variant.  Herpes on the palm.  Zoster presenting with large nodules. Etc.   In considering the list of most common diagnoses to involve liability, myocardial infarction, stroke, PE, Cancer of all kinds…I doubt the misdiagnosis occurred because a physician missed a typical presentation.  One of the many points that Larry Weed started making over 40 years ago was that the human mind just cannot remember all this variation, particularly across all specialties and also the questions to ask.  So medical students are typically lectured and instructed with prototypical “classic cases” and expected to generalize their thinking to variant presentations in the real world once they are in practice.  It is a flawed premise. Particularly when generalists might see a different patient every 20 minutes.   Databases, search and interface technology has been developed by us to provide the clinician with tools they use in real time to visualize variation, and to be able to compare patterns of symptoms, signs etc.  Though we started with skin, eye, oral we started thinking about the visualization of the complexity of internal disease.  We spend our time thinking about how to profile diseases to represent the variant presentations so that an end user for instance can recognize not just the patient that presents with left arm pain, chest pain, and diaphoresis as MI, but can also recognize a 60 year old with a toothache and fatigue as having an MI.  Prior efforts in diagnostic clinical decision support have reminded clinicians with a list of diseases, many very rare.  A key problem is we need to build into our systems the variation of common and known, not just reminders about the rare diseases.  <o:p></o:p></span></p><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D">Best<o:p></o:p></span></p><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D">Art<o:p></o:p></span></p><p class="MsoNormal"><!--[if gte vml 1]><v:shapetype id="_x0000_t75" coordsize="21600,21600" o:spt="75" o:preferrelative="t" path="m@4@5l@4@11@9@11@9@5xe" filled="f" stroked="f">
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</v:shape><![endif]--><image007.png> <image008.jpg><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D"><o:p></o:p></span></p><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="background:white;border-collapse:collapse"><tbody><tr style="height:1.4in"><td valign="top" style="padding:0in 6.0pt 0in 0in;height:1.4in"><p class="MsoNormal" align="right" style="text-align:right"><b><span style="font-family:"Calibri",sans-serif;color:#333333">Art Papier MD</span></b><span style="font-family:"Calibri",sans-serif;color:#333333"><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><span style="font-size:11.5pt;font-family:"Calibri",sans-serif;color:#333333">CEO</span><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333"><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><b><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#4BC4DB">phone</span></b><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"> </span><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#655656">585-272-2630</span><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><b><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#4BC4DB">mobile</span></b><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"> </span><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#655656">585-615-8245</span><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><b><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#4BC4DB">address</span></b><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"> </span><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#655656">339 East Ave, Suite 410 Rochester, NY 14604</span><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><b><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#4BC4DB">web</span></b><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"> <a href="http://visualdx.com/" target="_blank"><span style="font-size:8.5pt;color:#655656;border:none windowtext 1.0pt;padding:0in;text-decoration:none">visualdx.com</span></a><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><b><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#4BC4DB">email</span></b><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"> </span><span style="font-size:8.5pt;font-family:"Calibri",sans-serif;color:#D2DFE8;border:none windowtext 1.0pt;padding:0in"><a href="mailto:apapier@visualdx.com"><span style="color:#CCCCCC;text-decoration:none">apapier@visualdx.com</span></a></span><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p></o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p> </o:p></span></p><p class="MsoNormal" align="right" style="text-align:right"><a href="http://facebook.com/visualdx" target="_blank"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#00B1CF;border:none windowtext 1.0pt;padding:0in;text-decoration:none"><image001.jpg></span></a><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333">  </span><a href="http://www.twitter.com/visualdx" target="_blank"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#00B1CF;border:none windowtext 1.0pt;padding:0in;text-decoration:none"><image002.jpg></span></a><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333">  </span><a href="http://linkedin.com/company/logical-images" target="_blank"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#00B1CF;border:none windowtext 1.0pt;padding:0in;text-decoration:none"><image003.jpg></span></a><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333">  </span><a href="http://instagram.com/visualdximages" target="_blank"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#00B1CF;border:none windowtext 1.0pt;padding:0in;text-decoration:none"><image004.jpg></span></a><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333"><o:p></o:p></span></p></td><td valign="top" style="border:none;border-left:solid #D2DFE8 1.0pt;padding:0in 0in 0in 6.0pt;height:1.4in"><p class="MsoNormal"><a href="http://www.visualdx.com/"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333;text-decoration:none"><image005.png></span></a><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p></o:p></span></p><p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p> </o:p></span></p><p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p> </o:p></span></p><p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#333333"><image006.jpg></span><span style="font-size:10.0pt;font-family:"Calibri",sans-serif;color:#D2DFE8"><o:p></o:p></span></p></td></tr></tbody></table><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D"><o:p> </o:p></span></p><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D"><o:p> </o:p></span></p><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D"><o:p> </o:p></span></p><p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif;color:#1F497D"><o:p> </o:p></span></p><div><div style="border:none;border-top:solid #E1E1E1 1.0pt;padding:3.0pt 0in 0in 0in"><p class="MsoNormal"><b><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">From:</span></b><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"> Elias Peter [mailto:pheski69@GMAIL.COM] <br><b>Sent:</b> Thursday, February 25, 2016 9:12 AM<br><b>To:</b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG"><a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a></a><br><b>Subject:</b> Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club<o:p></o:p></span></p></div></div><p class="MsoNormal"><o:p> </o:p></p><p class="MsoNormal">We shouldn’t forget that there are two kinds of variation.<o:p></o:p></p><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal">When we talk about eliminating variation we generally mean eliminating clinician or system based inappropriate variation, exemplified starkly by the hip fracture repair done the same day on a Tuesday morning but delayed several days if it occurs on a weekend, or by the different patterns of test ordering or treatment recommendations by different clinicians based not on the clinical setting or evidence, but upon their personal pattern.<o:p></o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal">If we are not careful, in our attempt to eliminate inappropriate variation, we will forget that:<o:p></o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><ol start="1" type="1"><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l0 level1 lfo1">Patients are, in fact, variable. It is not appropriate standardization to treat two different patients the same because their LDL is the same, without taking into account differences in global risk and preferences/values.<o:p></o:p></li><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l0 level1 lfo1">Our evidence and algorithms are tentative, imperfect, and in need of conscious and monitored variation if we want to improve them. Whenever we develop a standardized algorithm, the understanding should be that this is where the discussion and decision making begins, not where it ends. The clinician should be allowed (I would argue, expected) to alter the algorithm in individual circumstances, BUT this needs to be accompanied by documentation of how and why the algorithm was modified, and a system to collect and analyze outcomes to identify opportunities to improve the algorithm.<o:p></o:p></li></ol><div><p class="MsoNormal"><o:p> </o:p></p></div></div><div><p class="MsoNormal">The ATM analogy is flawed. It applies to the simple and mechanical process of registering when one arrives for an appointment. It does not apply to the non-serial process of collecting a history, doing an exam, obtaining additional testing, integrating that information into a differential diagnosis, and working out a plan with the patient honoring their values and preferences. We haven’t built a machine that can do that yet.<o:p></o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal">In fact, I think that long before we can build a machine that does all of what a skilled clinician does when working with a patient, health care administrators and managers will long since have been replaced by machines. (I don’t mean that as a snark.)<o:p></o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal">Peter<o:p></o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p></div><div><p class="MsoNormal"><o:p> </o:p></p><div><blockquote style="margin-top:5.0pt;margin-bottom:5.0pt"><div><p class="MsoNormal">On 2016.02.25, at 7:33 AM, DR WILLIAM CORCORAN <<a href="mailto:williamcorcoran@SBCGLOBAL.NET"><a href="mailto:williamcorcoran@SBCGLOBAL.NET">williamcorcoran@SBCGLOBAL.NET</a></a>> wrote:<o:p></o:p></p></div><p class="MsoNormal"><o:p> </o:p></p><div><div><div><div id="yiv4536589150"><div id="yui_3_16_0_1_1456356321704_39795"><div id="yui_3_16_0_1_1456356321704_39794"><div id="yiv4536589150yui_3_16_0_1_1456356321704_35350"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35354"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">The healthcare industry is accepting the unacceptable: variation.<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35358"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35362"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">I can put my debit card into any ATM in the U.S. and the ATM will treat me like the ATM in my local branch bank.<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35366"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35370"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">But if I present myself for healthcare diagnosis, the result will vary all over the ball park. It will not only depend on which provider I go to, it will also depend on the time of day, the day of the week, etc. (I have two deceased family members who departed prematurely with wrong diagnoses involved.)<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35374"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35378"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">What’s wrong with this picture? My diagnosis should be solely dependent on my health condition.<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35382"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35386"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">“Variation is evil.” Jack Welch @ <a href="https://youtu.be/aNMULFcLuIM" target="_blank" id="yiv4536589150yui_3_16_0_1_1456356321704_35388"><a href="https://youtu.be/aNMULFcLuIM">https://youtu.be/aNMULFcLuIM</a></a><o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35392"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35396"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">There needs to be an outraged uprising of the healthcare industry to drive a stake through the heart of this problem.<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35400"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35404"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">If it is left to the patients and their survivors it will be taken over by the politicians and we won’t like the result.<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35408"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35412"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">The end goal is 100% accurate diagnosis consistently reliable anywhere in the system. If it is achieved one place it can be rolled out at every place. <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35416"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35420"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">Every shortfall needs good investigation.<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35424"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35428"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">“A problem cannot be solved with the same mindset that created it.”-Einstein?<o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35435"><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div id="yiv4536589150yui_3_16_0_1_1456356321704_35434"><div id="yiv4536589150yui_3_16_0_1_1456356321704_35433"><div id="yiv4536589150yui_3_16_0_1_1456356321704_35432"><p class="MsoNormal" style="background:white"><span style="font-family:"Arial",sans-serif">Take care,<br> <br>Bill Corcoran<br><br> <br>William  R. Corcoran, Ph.D., P.E.<br>21 Broadleaf Circle<br>Windsor, CT 06095-1634<br>860-285-8779<br><a href="mailto:William.R.Corcoran@1959.USNA.com"><a href="mailto:William.R.Corcoran@1959.USNA.com">William.R.Corcoran@1959.USNA.com</a></a><br></span><a name="webProfileURL" id="yui_3_16_0_1_1456356321704_40475"></a><a href="http://www.linkedin.com/in/williamcorcoranphdpe" target="_blank" title="View public profile"><span style="font-family:"Helvetica",sans-serif">http://www.linkedin.com/in/williamcorcoranphdpe</span></a><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div id="yui_3_16_0_1_1456356321704_40478"><p class="MsoNormal" style="margin-bottom:12.0pt"><span style="font-family:"Arial",sans-serif"><a href="https://www.box.com/shared/kfxg1lt9dh"><a href="https://www.box.com/shared/kfxg1lt9dh">https://www.box.com/shared/kfxg1lt9dh</a></a> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div></div><div id="yui_3_16_0_1_1456356321704_40481"><p class="MsoNormal" style="margin-bottom:12.0pt;background:white"><span style="font-family:"Helvetica",sans-serif"><o:p> </o:p></span></p></div></div></div></div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Arial",sans-serif">On Thursday, February 25, 2016 6:45 AM, Bob Latino <<a href="mailto:blatino@reliability.com"><a href="mailto:blatino@reliability.com">blatino@reliability.com</a></a>> wrote:</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><blockquote style="border:none;border-left:solid #1010FF 1.5pt;padding:0in 0in 0in 4.0pt;margin-left:3.75pt;margin-top:3.75pt;margin-bottom:5.0pt"><p class="MsoNormal" style="margin-bottom:12.0pt;background:white"><span style="font-family:"Helvetica",sans-serif"><o:p> </o:p></span></p><div><div id="yiv4536589150"><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Hi Bill</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">I know Geri Amori below who found the comment below 'fascinating'.  She is considered a Risk Management Guru in the HC world.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Why is that comment a revelation in HC when it has been commonplace in industry for decades?</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">These people appear to me to be trying to tackle Diagnosis Error like it is a singular event.  They are not concerned with breaking it down into its manageable components and understanding what comprises 'Diagnosis Error'.  They can't even define what it is and collect data accordingly to know the magnitude of the problem.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Being a relative newbie to this group, what impressions do you have about how HC solves it problems and why they are so far behind industry in how to tackle solving complex problems?</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Just curious, because my time on this forum has just encouraged me to stay healthy and not have to use a hospital unless absolutely necessary.  They don't give much credence to 'outsiders' input on this forum, as they seem to be above that (my opinion of course).</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Hope all is well in sunny FL.  We had a round of tornados locally last night, so FL is looking really attractive these days:-)</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Bob</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><p class="MsoNormal" style="background:white"><b><span style="font-family:"Helvetica",sans-serif;color:#1F497D">Robert J. Latino, CEO</span></b><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Reliability Center, Inc.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">1.800.457.0645</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"><a href="mailto:blatino@reliability.com"><a href="mailto:blatino@reliability.com">blatino@reliability.com</a></a></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"><a href="http://www.reliability.com"><a href="http://www.reliability.com">www.reliability.com</a></a></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div style="border:none;border-top:solid #E1E1E1 1.0pt;padding:3.0pt 0in 0in 0in"><div><p class="MsoNormal" style="background:white"><b><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif">From:</span></b><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif"> Geri Amori [<a href="mailto:gamori@COVERYS.COM"><a href="mailto:gamori@COVERYS.COM">mailto:gamori@COVERYS.COM</a></a>] <br><b>Sent:</b> Wednesday, February 24, 2016 8:59 PM<br><b>To:</b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG"><a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a></a><br><b>Subject:</b> Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D">This is a fascinating comment.  We have always penalized the “miss” and  not penalized when the incorrect or work-around process has not harmed.  This has been a long noted concern for  Just Culture and in Patient Safety science.  For example, when people have engaged in work-arounds that did not harm the patient, we ignored them.  Sometimes we even praised the folks who managed to “save” the day.  But if a patient happens to be harmed by the same work around we punish or fire the protagonist and call them names like “negligent” often for the very same behavior.  It’s the same phenomena in diagnostic error:   We order something looking for the zebra, we are over-testing;  we decide not to test but to treat based on probability, we are over-treating;  we decide not to test and not to treat and we are negligent.  Where is the balance? </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D">It may well be that there IS no balance and that we as a society and a field decide which of the “evils” is better for patients….Is it better not to test or treat and risk missing some diagnosis?  In a culture of autonomy that will not be easily accepted by the courts or by patients themselves.  Is it better to risk over diagnosis through extensive testing.  Literature has shown that patients feel better knowing they have been tested, but what does that do to payer issues….and what about those patient who undergo unnecessary treatment because of a chance finding that perhaps didn’t need to be treated.  That leads to over treatment…another conundrum.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D">What is better for patients?  What is healthiest for providers and the system?  How do we decide?</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D">I think it’s up to those of us who care about this issue to propose what the guidelines should be.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Geri Amori, PhD, ARM, CPHRM, DFASHRM</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Vice President, Academic Affairs</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">P: 617.526.0360</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-right:4.5pt"><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">C: 802.238.5652</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-right:4.5pt"><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><b><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#0067AC">COVERYS</span></b><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">One Financial Center <br>Boston, MA 02111</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"><a href="http://www.coverys.com/" target="_blank"><span style="font-size:10.0pt">www.coverys.com</span></a></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">1.800.225.6168</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><b><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif">From:</span></b><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif"> Tom Benzoni [<a href="mailto:benzonit@GMAIL.COM" target="_blank"><a href="mailto:benzonit@GMAIL.COM">mailto:benzonit@GMAIL.COM</a></a>] <br><b>Sent:</b> Wednesday, February 24, 2016 5:50 PM<br><b>To:</b> <a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank"><a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a></a><br><b>Subject:</b> Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">It would be helpful to keep in mind there is error on both sides:<o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">If I order a CTA of the lungs to rule out a PE in low probability patient, I've made an error.<o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">If that CTA comes back with a maybe reading and I start anticoagulants, I've made an error that carries risk of harm that exceeds risk of benefit.<o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">Yet we penalize only the miss, not the incorrect (+).<o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">tom<o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif">On Wed, Feb 24, 2016 at 2:42 PM, Charlene Weir <<a href="mailto:charlene.weir@utah.edu" target="_blank"><a href="mailto:charlene.weir@utah.edu">charlene.weir@utah.edu</a></a>> wrote:<o:p></o:p></span></p></div><blockquote style="border:none;border-left:solid #CCCCCC 1.0pt;padding:0in 0in 0in 6.0pt;margin-left:4.8pt;margin-top:5.0pt;margin-right:0in;margin-bottom:5.0pt"><div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">Iliad was developed at UU by Homer Warner and group as a diagnostic decision support system. The best feature, I thought, was the ability to offer what is the next best piece of information to gather. . .</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><pre style="background:white"><span style="font-family:Chalkduster">Charlene </span><o:p></o:p></pre></div></div></div></div><div style="border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0in 0in 0in"><div><p class="MsoNormal" style="background:white"><b><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif">From: </span></b><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif">Elias Peter <<a href="mailto:pheski69@GMAIL.COM" target="_blank"><a href="mailto:pheski69@GMAIL.COM">pheski69@GMAIL.COM</a></a>><br><b>Reply-To: </b>Society to Improve Diagnosis in Medicine <<a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank"><a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a></a>>, Elias Peter <<a href="mailto:pheski69@GMAIL.COM" target="_blank"><a href="mailto:pheski69@GMAIL.COM">pheski69@GMAIL.COM</a></a>><br><b>Date: </b>Wednesday, February 24, 2016 at 1:17 PM<br><b>To: </b>"<a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank"><a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a></a>" <<a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG" target="_blank"><a href="mailto:IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG">IMPROVEDX@LIST.IMPROVEDIAGNOSIS.ORG</a></a>><br><b>Subject: </b>Re: [IMPROVEDX] Diagnostic Error in Medicine Journal Club</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">Great question. I parse it this way:</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><ul type="disc"><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l2 level1 lfo2;background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">No normal clinician is capable on the fly of generating the exhaustive list, let alone put them in order of probability.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></li><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l2 level1 lfo2;background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">A computer might do this pretty well, but it depends on the back end programming and the data entered.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></li><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l2 level1 lfo2;background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">It still depends on someone  (not necessarily the clinician) having the skill and taking the time to enter the data.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></li><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l2 level1 lfo2;background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">It would probably decrease the number of diagnoses missed because of the availability heuristic and because of lack of knowledge.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></li><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l2 level1 lfo2;background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">It would still run the risk of increased and possibly unnecessary/inappropriate testing. (“The computer suggested splenic artery aneurysm as a cause of LUQ pain, so why didn’t you order imaging at that visit?”) This could be minimized by setting it to provide the top 3 or top 5 probabilities, annotated, and give a larger list only upon request. I might want to see 3-5 options for common and simple problems at the first visit, but be able to expand the list if the patient has new symptoms, doesn’t improved...</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></li></ul><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">A tool like this is definitely on my wish list, but I would want it field tested and data about NNT/NNH, impact on time, etc.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">Peter</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><blockquote style="margin-top:5.0pt;margin-bottom:5.0pt"><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">On 2016.02.24, at 2:53 PM, Cameron Powell <<a href="mailto:cameron@PHYSICIANCOGNITION.COM" target="_blank"><a href="mailto:cameron@PHYSICIANCOGNITION.COM">cameron@PHYSICIANCOGNITION.COM</a></a>> wrote:</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">Peter, would you say the same thing when the exhaustive list is produced automatically, either immediately upon the physician's input of relevant variables or even before the patient reaches the physician? If they’re in probabilistic order? </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">Studies have shown that when doctors are presented with an intelligent list of differentials, they do make higher quality decisions.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">Cameron</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif;color:#646464"><br>Appfully Yours (</span><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"><a href="https://play.google.com/store/apps/details?id=com.physiciancognition.xebrapro" target="_blank">Android</a></span><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif;color:#646464"> | </span><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"><a href="https://itunes.apple.com/us/app/xebra-pro/id1051676634" target="_blank"><span style="font-size:10.5pt;color:#646464">IOS</span></a></span><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif;color:#646464">),</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><b><span style="font-size:13.5pt;font-family:"Helvetica",sans-serif;color:#00A1E6">Cameron Powell</span></b><b><span style="font-size:13.5pt;font-family:"Helvetica",sans-serif;color:#646464">  |  </span></b><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif;color:#646464">CEO, Physician Cognition, Inc.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif;color:#CCCCCC">  ———————————————————————</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">  </span><span style="font-size:10.0pt;font-family:Wingdings;color:#00A1E6">(</span><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">:  </span><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#8D8D8D"><span class="MsoHyperlink">503 502 5030</span> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">  </span><span style="font-size:10.0pt;font-family:Wingdings;color:#00A1E6">-</span><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">:  <a href="mailto:Cameron@physiciancognition.com" target="_blank"><a href="mailto:Cameron@PhysicianCognition.com">Cameron@PhysicianCognition.com</a></a></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">  </span><span style="font-size:10.0pt;font-family:Wingdings">:</span><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">:   </span><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif"><a href="http://physiciancognition.com/" target="_blank"><a href="http://PhysicianCognition.com">PhysicianCognition.com</a></a></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">  <a href="https://www.facebook.com/Physician-Cognition-1542884199311822/" target="_blank">Facebook</a></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">  <a href="https://twitter.com/PhysicianCog" target="_blank">Twitter - Company</a> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">  <a href="http://www.twitter.com/cameroncpowell" target="_blank">Twitter - Personal</a> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div></div></div></div></div></div><div><div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif;color:#00A1E6">“Wow. This Thing Is Better Than I Am!” — CMO, Major Urban Hospital, And Many Others</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div></div></div></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"><br><PhysicianCognitionLogo_email.png></span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><blockquote style="margin-top:5.0pt;margin-bottom:5.0pt"><div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif">On Feb 23, 2016, at 6:45 PM, Elias Peter <<a href="mailto:pheski69@gmail.com" target="_blank"><a href="mailto:pheski69@GMAIL.COM">pheski69@GMAIL.COM</a></a>> wrote:</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">I have two objections to this.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">The first relates to resources. From the perspective of a primary care physician, the “...creation of an exhaustive differential diagnosis listing all diseases regardless of prior probabilities in every patient…” would mean I make very few diagnostic errors on the two or three patients I see every day. </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">Even in something as mundane as a sore throat this is not realistic: self limited multiple viruses, GABHS, non-group A strep, diphtheria, mononucleosis, Lemierre’s, GC, HIV, herpes, coxscakie, malignancy, GERD, sinusitis, voice abuse, dry air, foreign body. For abdominal pain…</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">The second is that an exhaustive list of possibilities is likely to lead to considerable unnecessary testing and false positives with further testing, over diagnosis and over treatment. </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">Peter Elias, MD</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:10.5pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><blockquote style="margin-top:5.0pt;margin-bottom:5.0pt"><div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif">On 2016.02.19, at 7:48 AM, Jain, Bimal P.,M.D. <<a href="mailto:BJAIN@PARTNERS.ORG" target="_blank"><span style="color:purple">BJAIN@PARTNERS.ORG</span></a>> wrote:</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:9.0pt;font-family:"Helvetica",sans-serif"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">As I shall not be able to attend the DEM Journal Club on Thursday, March 3, I present here my thoughts on Dr. Thompson’s important paper on diagnostic errors in primary care.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">1.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">The main reason for failure to suspect a disease when its presentation was atypical was ,as Dr. Thompson points out, reliance on pattern recognition.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">2.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Reliance on pattern recognition is, I believe, a cognitive bias similar to or the same as representativeness in which a disease with atypical features is not suspected(Ely, Graber, Croskerry Acad. Med. 86: 2011, 307-313).</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">3.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">In pattern recognition as well as in representativeness, the typicality of a presentation or frequency of a disease given a presentation is considered evidence for or against that disease in a given, individual patient.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">4.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Thus the low frequency or low prior probability of a disease in a patient with atypical presentation is considered prior evidence against that disease which may then not be suspected.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">5.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">We note that a probabilistic approach to diagnosis in which prior probability represents prior evidence may actually promote failure to suspect a disease in patient with atypical presentation.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">6.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">This diagnostic error has also been reported by H. Singh et al( JAMA Intern Med Published online Feb 25 2013 48-25) and John Ely et al (JABFM 25: 2012 87-97)</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">7.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">The best way to eliminate this diagnostic error is to understand that atypicality of a presentation or low prior probability of a disease is not evidence against it in a given, individual patient.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">8.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">The creation of an exhaustive differential diagnosis listing all diseases regardless of prior probabilities in every patient as is done in CPCs in NEJM and then evaluating each disease in it by its ability to explain patient findings would go a long way in reducing or eliminating this diagnostic error.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">9.</span><span style="font-size:7.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">       </span><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">With this approach one hundred diagnostic accuracy was achieved in 50 CPCs that I reviewed recently.</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-left:.5in"><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Bimal</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-left:.5in"><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Bimal P Jain MD</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Pulmonary-Critical Care</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Northshore Medical Center</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div style="margin-left:.5in"><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D">Lynn MA 01904</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><p class="MsoNormal" style="background:white"><span style="font-size:11.0pt;font-family:"Helvetica",sans-serif;color:#1F497D"> </span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div><div><div style="border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0in 0in 0in"><div><div><p class="MsoNormal" style="background:white"><b><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif">From:</span></b><span style="font-size:10.0pt;font-family:"Helvetica",sans-serif"> Society to Improve Diagnosis in Medicine [<a href="mailto:info@improvediagnosis.org" target="_blank"><span style="color:purple">mailto:info@improvediagnosis.org</span></a>] <br><b>Sent:</b> Wednesday, February 17, 2016 6:05 PM<br><b>To:</b> Jain, Bimal P.,M.D.<br><b>Subject:</b> Diagnostic Error in Medicine Journal Club</span><span style="font-family:"Helvetica",sans-serif"><o:p></o:p></span></p></div></div></div></div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"> <o:p></o:p></span></p></div></div><div><div><div><p class="MsoNormal" style="background:white"><span style="font-family:"Helvetica",sans-serif"><img border="0" width="1" height="1" id="yiv4536589150_x005f_x0000_i1025" src="http://r20.rs6.net/on.jsp?ca=0ba05b94-1723-406e-8370-e2f99b8f5979&a=1110757552861&d=1123832518321&r=3&o=http://ui.constantcontact.com/images/p1x1.gif&c=616a9fc0-82c6-11e3-b074-d4ae529a824a&ch=61a18e40-82c6-11e3-b0cb-d4ae529a824a"><o:p></o:p></span></p></div></div><div><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:1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ssons learned from diagnostic errors in primary care. BR J  Gen Pract. 2015 1;65 (641) :e838-44. </span><o:p></o:p></p><p class="MsoNormal" align="center" style="text-align:center"><span style="color:#717171">Accessible at <a href="http://r20.rs6.net/tn.jsp?f=001NXIoYwDLr83bLGFfGtb0LURm3bKmVW_jRoNgrMyFVqdy-a3tiQYyOYLunYmWPsic0OduilTzPf_fhHnr60XrkRGEpXElm8G-0t7slabepsDnaEm4ADwwqcZ_5a8KuEn2x6mmQop-q1tcHlBColHWy0XW5Wl-GsZstheaIJnkPWWAoI36GaQ19VFNDMZTT0BxZ9sVuvcKi4w=&c=gsgqHa0vIyo2c-7PoWTxwP3mDi_ElXGpdNt2cNd-wDtsoMidc5a8aA==&ch=yOonVj2aA6Ashu-lrk3ZGxD-vHGFOIteuKNP-r9zuzMNd9y9xEmMjQ==" target="_blank"><span style="color:purple">http;//bjgp.org/content/65/641/e838.long</span></a>  </span><o:p></o:p></p><p class="MsoNormal" align="center" style="text-align:center"><span style="color:#717171">Physicians, healthcare professionals and researchers working in the field of diagnostic error are welcome to register for the session using the link below.</span><o:p></o:p></p><p class="MsoNormal" align="center" style="text-align:center"><em><span style="color:#717171">Participation is free.</span></em><o:p></o:p></p></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%"><tbody><tr><td valign="top" style="padding:6.0pt 0in 6.0pt 0in"><div><p class="MsoNormal" align="center" style="text-align:center"><i><span style="font-size:18.0pt;color:#00B397">When</span></i><o:p></o:p></p></div></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%"><tbody><tr><td valign="top" style="padding:5.25pt 7.5pt 5.25pt 7.5pt"><div><p class="MsoNormal" align="center" style="text-align:center"><b><span style="color:#717171">Thursday, March 3, 2016<br></span></b><span style="color:#717171">From 1pm - 2pm CT</span><o:p></o:p></p></div></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%"><tbody><tr><td valign="top" style="padding:6.0pt 0in 6.0pt 0in"><div><p class="MsoNormal" align="center" style="text-align:center"><i><span style="font-size:18.0pt;color:#00B397">Where</span></i><o:p></o:p></p></div></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%"><tbody><tr><td valign="top" style="padding:5.25pt 7.5pt 5.25pt 7.5pt"><div><p class="MsoNormal" align="center" style="text-align:center"><strong><span style="color:#717171">Free Online Webinar</span></strong><o:p></o:p></p></div></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%;display:table"><tbody><tr><td valign="top" style="padding:0in 0in 0in 0in"><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" style="background:#F26522"><tbody><tr><td valign="top" style="padding:3.75pt 22.5pt 3.75pt 22.5pt"><div><p class="MsoNormal" align="center" style="text-align:center"><b><span style="font-size:10.0pt;color:white"><a href="http://r20.rs6.net/tn.jsp?f=001NXIoYwDLr83bLGFfGtb0LURm3bKmVW_jRoNgrMyFVqdy-a3tiQYyOYLunYmWPsiciW2sURAy0Zh459qndkE-1RHQmudM-dzj7tCoEW4RKoyAEREhuhF5MBxx5oglG9fUw4dFEh3yb0x2OVwUUCFNfY4a3cihOr3T-bIwC3B8n_B1dEiiA7R2CY0D_wcCudqplcznVaX5qwKRSzaJAGT8ohy4BMkVaW3V&c=gsgqHa0vIyo2c-7PoWTxwP3mDi_ElXGpdNt2cNd-wDtsoMidc5a8aA==&ch=yOonVj2aA6Ashu-lrk3ZGxD-vHGFOIteuKNP-r9zuzMNd9y9xEmMjQ==" target="_blank"><span style="color:white;text-decoration:none"> Register Here!</span></a> </span></b><o:p></o:p></p></div></td><td style="padding:0in 0in 0in 0in"></td></tr></tbody></table></div></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="100%" style="width:100.0%"><tbody><tr style="height:.75pt"><td valign="top" style="padding:0in 0in 6.0pt 0in;height:.75pt"><p class="MsoNormal" align="center" style="text-align:center"><img border="0" width="5" height="1" id="yiv4536589150_x005f_x0000_i1028" src="http://img.constantcontact.com/letters/images/1101116784221/S.gif"><o:p></o:p></p></td></tr></tbody></table></div></td></tr></tbody></table></div></td></tr></tbody></table></div></td></tr></tbody></table></div><p class="MsoNormal" align="center" style="text-align:center"> <o:p></o:p></p><div align="center"><table class="MsoNo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<br>Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine<br>

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<br />Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine<br />

<br />To learn more about SIDM visit:<br>http://www.improvediagnosis.org/</p>